Your Questions

Q: Dr. Eppley, I’m 18 and 5’6 tall and weight 130. I was born with a big head. I’m so insecure about myself seeing everyone around me with a smaller head makes me depressed. I’m planning on having a head reduction if that even exists?? The top of my head is wide and long.I have a perfect idea on what parts of my skull can be removed in order for my head to look smaller. I’m also thinking that maybe my jaw makes my head look big as well so I’m guessing you could probably help me out?

A:  I often have patients come to my Indianapolis plastic surgery center asking me how to get a smaller head. Unfortunately, the reality is that the concept of skull reduction for a larger head is limited as it is simply not possible to make a big head much smaller. From your statement that your jaw is what makes your head look big, it suggests to me that your jaw is currently small or recessed. With that in mind, I would suggest that you consider a jaw enhancement procedure as opposed to skull reshaping surgery, as making the jaw bigger and more defined is a much more attainable goal. I would need to see pictures of your face/head to determine what, if anything, can be done to improve your perception of a skull-face disproportion.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hello, I am inquiring about laser surgery stretch mark removal. I have abdominal stretch marks just above and below the belly button due to pregnancy and I wanted to know what could possibly be done about this. I would also want information on pricing. Thanks very much!

A:  Thank you for your inquiry. As much as I would like to tell you that ‘laser stretch mark removal’ is a real entity, it is not. Lasers can be used to treat stretch marks and there may be some improvement, but the concept of complete removal of their appearance is not currently possible. Stretch marks represensent partial tears in the dermis of the skin and, once such injured, the skin can never be restored to normal skin again. It is not possible to regenerate the lost thickness of the dermis which is why they are wide and somewhat depressed. I would need to see some pictures of your periumbilical area to see if laser treatments would be of any benefit at all.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  I have an infected chin implant and would like to have the implant replaced at the same time if it  would prevent ptosis. Aesthetically, I am very satisfied with the implant. The only reason I am having it removed is because of the infection. Its just that my surgeon was saying (which I guess is the standard procedure) to wait four months to have it replaced. He said that he would do the replacement implant through the skin. What about replacing it and using antibiotic beads to reduce risk of reinfection? Is that possible or recommendable? Should I replace it with another medpor or silicone implant?  Really for efficiency purposes it would be great if I could get it replaced in one surgery instead of two. Thank you.

A: one important question is why did this chin implant get infected so late after placement? This is important to know because you want to be able to avoid re-creating the very problem that caused it in the first place. My suspicion is that a large medpor implant placed through the mouth may have resulted in tissue thinning intraorally. That would be most evident if there were drainage holes from inside the mouth. In this scenario, it would be best to remove it from below, excise and close the intraoral tracks and secure a new implant as low on the chin bone as possible.  The replacement should likely be a non-porous chin implant if you can get a replacement that has similar dimensions to what you have now. Do you know the catalog # and/or description and size of the implant you have in now. (there are only so many styles in Medpor…contoured two-piece, RZ extended (round or square) or two-piece chin) I am not opposed to an immediate Medpor replacement as it does have the potential to be infused with a Vancomycin solution. The antibiotic bead concept is an old one from Orthoopedic surgery using impregnanted PMMA beads. But the dimension of these beads, while good for a hip or knee, are too big for the chin area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am ready to get my infected chin implan removed but since it is my face I want to make sure I’m getting the most qualified person to do it. If you were in my place are there any particular questions or concerns that I should make sure my surgeon has dealt with to reduce risk of nerve damage, ptosis since it is a pretty large implant? The implant was placed through the mouth. Also have you ever used hyperbaric oxygen therapy? Could it help reduce post operation healing time? How many work days would I need to take off to be able to return to work? Would you use any head dress?

A: In theory , any surgeon that places chin implants should be able to remove them. The issue that you need to be aware of, particularly since this is a big implant and you are removing it from inside the mouth and are not replacing it, is the high likelihood that chin ptosis will result. (sagging of chin tissues off of the bone since that are now stretched)You will likely need a simultaneous muscle resuspension done at the same time to avoid this potential aesthetic problem. There is no benefit to hyperbaric oxygen (HBO) therapy in surgical removing an infected chin implant. HBO has benefit in irradiated tissues where the native blood supply is compromised. If the muscle is resuspended to the bone, there is no need for a chin dressing afterwards. A chin dressing is not going to prevent chin soft tissue sagging anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have a medpor chin implant that I have had since 2008. It has become infected. I am taking antibiotics and soon I will have it removed. I don’t think my surgeon has ever removed a medpor chin implant. In your opinion is it too risky to have someone how hasn’t removed one before perform this surgery? How many medpor chin implants have you removed? Thank you.

A: Thank you for your inquiry. That is most unusual to develop an infection in a chin implant that has been in for years. Regardless, removal is the appropriate treatment now. I have removed/replaced numerous medpor facial implants over the years, most commonly the chin and jaw angle areas. Most of these have been for aesthetic purposes where they are well integrated into the tissues and can be challenging but successfully removed. I have done very few for infection reasons but they are always a little easier as they may not have ares that have a tight tissue bone due to the infection. I can not comment on whether your surgeon is up to the task in removing it but they should be prepared that it will not just slide or jump out like a silicone chin implant would.

The other issue you have to ponder is whether you want to do an immediate replacement or not. Some surgeons prefer to wait several months which is the standard approach while immediate replacement with a new chin implant can also be successful but with a slightly higher risk of recurrent infection. This can be successful because the infection is mostly in the porous material which, once removed, eliminates the primary source of the infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, many thanks for your email reply and I have attached some more pictures. Hope they are of the correct type – if you need better quality or closer views I can arrange that. As you can see I’ve taken photos of my profile many times and at varying body weights. The thinner I am the better my jawline looks, obviously, but I find it difficult to maintain the weight that allows this (roughly 50kg) – also I worry about when I get pregnant that I will look terrible with a big double chin.
My main concerns are that, from the front, my lower face looks chubby with jowls just to the right and left of my chin. I feel this makes me look really young but not in a good way!Like a chubby little girl! From a side(but not complete profile) view the jaw line gets hazy-looking about halfway along. In profile my chin just looks really weak which, to be honest, I wouldn’t mind so much but its the fact that this causes my neck structures to be poorly supported and therefore have a double chin. I also feel that my lower jaw is asymetrical and this can be seen from the front? Think that the left side of jaw is shorter making jowls worse on that side?
I have pushed my lower jaw out in some of the pics to get a view of what things might look like if I have a better jaw line/chin but obviously this gives me a horrible underbite and can’t walk around looking like that all day! But thought you might be interested to see the jawline I have in mind and I would hope for.
I included a pic of me at a lower weight to show you the effect of that as well….maybe I just need to knuckle down and lose the weight because currently I eat whatever I want and do NO EXERCISE at all…very bad I know!
Feel that my nose is quite fat looking at the lower portion from the front although I don’t have too much of an issue with the view in profile. Can something be done to make nose less bulbous at the end? This is definitely less of a concern for me the as it’s my chin that I really hate and think about it pretty much every day and am self conscious about it.
Many thanks.

A:  Thank you for sending your pictures. What they show and you demonstrate so well is that the chin/jawline is somewhat short. Lengthening the chin by jawline distraction produces a good improvement. This manuever demonstrates to me that a sliding genioplasty would be a better treatment choice than a chin implant. Moving the chin bone forward brings with it the the underlying neck musculature and, as a result, produces a better jawline/neck appearance. One may also consider submental liposuction with the chin advancement to ensure getting the best result possible. As for the jowl asymmetry, the chin bone would be advanced symmetrically and hopefully that will make an improvement in that concern as well.

As for the nose, that would require a straightforward tip rhinoplasty to thin the cartilages and make the tip less bulbous.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am 82 years old and want to have a facelift. Am I too old for plastic surgery? I stopped smoking 25 years ago and I think I am in pretty good health. I do take blood pressure medication and have a pacemaker.

A:  Even though you are not at the typical age of most facelift patients, you can have elective plastic surgery done with several caveats. It would be critical to first talk to your cardiologist and get both their clearance and to find out what type of pacemaker you have.  A pacemaker needs to be demagnetized prior to surgery since the electrocautery used during a facelift will cause the pacemaker to malfunction. Whether this is best done in a hospital location or can safely be done in an outpatient surgery center is a judgment for your cardiologist. Your blood pressure must also be under excellent control before a facelift to decrease the risk of a hematoma after surgery. Lastly it would be important to have a type of facelift that produces a good improvement but also limits the surgical time to do it and has a fairly quick recovery. Facelift surgery needs to be adjusted for the unique needs of each patient and, at your age, the need for safety supercedes the degree of facial change.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, can you tell is there a way of reducing the excess skin between the eyes (glabella area) and what is the procedure for that? Only the skin, not the bone or fat. Will there be a big scar after the surgery? Thank you!

A: Some people will develop deep vertical furrows between the eyebrows, also known as the glabellar area. These are the result of extreme muscle action of the glabellar musculature. These furrows can become so deep and excessive that in some people they will appear as actual rolls or vertical folds of skin. While Botox is the standard treatment for glabellar furrows, it will have little effect in reducing these glabellar skin rolls. I have actually done excisions of select vertical glabellar skin rolls. While this does create a dramatic flattening of the glabellar area, and one can also perform muscle excision at the inner eyebrows to create a more permanent Botox-like effect, it does result in a prominent scar if one has thicker type skin. (which is almost always in whom these skin rolls exist) In each and every case, I have needed to do subsequent scar revisions for an improvement in their appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  growing up I have been called all sorts of names, but the one I hated the most was flat head. I eventually grew my hair out as an adult and spiked it out or make it poofy in the back. I never thought it was possible to get your skull reshaped until I came upon reading your page, and taking a look at a couple of your operations. My head is flat posterior parietal to the occipital bone. I’m an Asian male, and not everyone has it, but it’s highly common in our race, but I absolutely hate it. I been wondering about the price of operation, and maybe consider it in the future. I have many times down myself into seeking this operation, or even research about it. I have a couple pictures of my head to show, but not sure where to put picture attachment. Please respond back, thank you.

A:  Thank you for your inquiry. About one-third of the patients that I perform surgery on for correction of a flat back of the head in one area or the other are of Asian descent. So I recognize the ethnic component to it. I would be happy to review any pictures of your head which you can attach as a reply to this e-mail. The typical cost range for an occipital skull augmentation procedure would be in the $7500 to $9500 range depending upon the volume of material needed and the time to do the procedure.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, here are a few photos of my necklift result. You can see that the results of my traditional neck lift were not bad, just not as well as I hoped for. I do have the lateral scar under my chin and scars behind my ears so my surgeon did tighten my skin. As I mentioned I do have a sharper jaw line and thinner neck but not quite the neck angle I expected. If I place my thumb in the crook of my neck and slightly pull the loose skin to one side, it looks exactly the way I wanted my surgery to turn out. If that can be achieved by a direct neck lift then I would consider that option. Can you tell me what that runs price wise and is it common enough that most surgeons would be adept at that procedure?

A:  While I have no idea what you looked like before your traditional necklift, those results look very good to me and are about the best you could have hoped for. Because of potential hairline and beard skin distortions and the heaviness of male facial skin, it is usually not possible to have a very sharp or close to 90 degree neck angle. To have thought otherwise suggests a fundamental misunderstanding in the preoperative consultation/education process.

A direct necklift can make that final change into a sharper neck angle if one has some tolerance for a midline neck scar in the depth of the neck angle area. Whether you would have a favorable scar depends on how tight the skin is in that area. Loose neck skin in the older male when a wattle is present heals remarkably well. Tight skin in a middle-aged male may be at higher risk for hypertrophic scarring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a question about necklift procedures. I am a 49 year old white male at 6’1″ and 230 in fairly good health. I had a neck lift 6 months ago to correct jowling and a progressively poor neckline. The liposuction reduced the circumference of my neck and sharpened my jaw line to my satisfaction. However it did not restore a better neck angle to my expectations. My surgeon is a very talented surgeon but he did not remove any neck skin and I think that might have improved the results. I cut and pasted the paragraph below from your webpage commentary. It sounds like you may use skin removal as a standard part of the overall necklift for best results. Is that common? If so why wouldn’t my surgeon have used it? Can I now have neck skin removal done as a stand alone procedure? If so what is the name of that specific procedure and what would it cost?

“In rare cases of the much older male (usually greater than 65) who has a large neck waddle and does not want or can not undergo a significant operation, the direct neck lift can be an option. Rather than using any incisions around the ears, the loose skin is cut out directly in the neck. This produces a pretty significant change that offers a much more limited recovery. And can be a consideration if the man can accept a scar running vertically down from the chin to the adam’s apple. Surprisingly that scar can heal very nicely due to it being in beard skin which scars less than non-beard skin most of the time.”

A: The question about your ‘necklift’ procedure is did you have skin removed through standard facelift incisions? If so, some call this a facelift while others call it a necklift. A facelift in a male typcially never gives the refinement in the neck angle like one sees in a female because the tissue are heavier and thicker and a less chised neck angle results. If you did not have skin removed through a facelift approach (incisions around the ears) then I am not surprised that simply defatting the neck, while making it less full, did not change the neck angle.

Directly excising neck skin, aka the direct necklift, while very effective is reserved for the older male who needs neck skin removed but does not want the greater complexity of a facelift operation even though it places the scar is a much more favorable location.

I would be happy to review pictures of your neck (side view most favorable) to see what your options may be at this point.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was wondering whether you performed any surgical procedures for the lengthening of a short upper lip without the use of injectables or fillers etc. I have been trying to find such a procedure for quite some time and have so far been unsuccessful.

I was wondering whether there was any way to lengthen the upper lip by approx. 6-7 mm, since when at rest most of my teeth are visible. Could you please let me know if you perform such a procedure and if such a result is achievable or if you are aware of any other surgeons who may be able to help me. Many thanks.

A: I suspect you are talking about correction of a gummy smile. There are no procedures that can add skin to the upper lip or lengthen it from the outside. Thus there is a reason you have not been successful in your search. There are procedures done on the inside of the upper lip where the vestibule is lowered (lengthening vestibuloplasty), thus pulling done (lengthening) the lip so some degree. It may also be that you have vertical maxillary excess (too much vertical upper jaw bone) that may also be the culprit in your case.

I would need to see some pictures of your face/lips, at rest and when smiling, to have a better idea as to whether this approach may be helpful for you.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was wondering approximately what cost I could expect for a nipple reduction? Breast size is 32B and nipples are nearly an inch long and half inch wide.  Because of their size, they are heavy and sag.The only thing I would be interested in would be a simple width/length reduction of the nipple and nothing with the breast or areola size.  I would also like to retain as much feeling as possible.  Thanks!

A: I will have my assistant forward that cost information to you. Most likely the cost will be around $1500. There are two different techniques for nipple reduction. The one that is the most effective at length reduction also runs the greatest risk of some loss of feeling. The nipple reduction technique that preserves the most sensation is the one that will produce a more limited amount of length reduction. No nipple reduction technique is very effective at reducing the diameter of the base of the nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a swelling on my right side of the head, and I noticed it 8-9 months ago. Yesterday I was in the hospital took computer tomography, and it showed that I have osteoma on my skull. So, mine is on my skull, but the pics shows that it can be insight the skull too  (not sure though). So, I talk to the doctor, and he says it should be removed. He suggested surgery as it can grow. What I don’t like doctor says they gonna remove first two layers of the skull. My bump is 3.5 x 3.5cm in diameters and 1.5cms in height.  So, doctor says he will remove 5×5 in diameters, and two layers of the skull, and then to fill in the hollow created due to the clearing away of the extra growth by cement. These all horrifies me. The thing is I don’t have any symptoms, I mean I never had head injury, don’t have head aches, nothing. So, can you please advise how you do this kind of surgery and how much it will cost me with you. If you need I can send my CT. Thank you in advance

A: Thank you for your inquiry. The question is whether your osteoma should be burred down or excised and replaced by bone cement. (as you your surgeon has suggested) Admittedly if I was a patient I would be a lot more interested in the burring approach, particularly for an asymptomatic osteoma. Please send me some pictures of your head showing that area and the CT scan for my assessment. Then I can give you a more fully informed opinion. But if the osteoma has no intracranial expansion, I would choose the burring reduction skull reshaping approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I like what I see, much more “chiseled” appearing. Would it be unnecessary to or insensible to increase the length of my chin to make it sort of protruding? I’ve always found that to be appealing/masculine. I know people get chin reductions to avoid that, but I’ve always liked that. If not, I feel that I see some flaw in my chin/jaw line that stands out to me. I’ve always wanted a stronger jaw/chin, maybe overly strong, beyond typical. Maybe it is my jaw? Would you recommend a possible jaw implant along with the rhinoplasty and chin implant? Do you think this would match my desired traits? I desire an angular sort of jaw, with a square appearing and strong chin, and my nose looks great after, but is there a way that it could be made that you couldn’t see the bottom of my nose? Its always made me self conscious that the bottom of my nose has been visible when i am looking at someone. I am sorry I’m asking so much, I just want to make sure that I am 100% pleased with the procedure and I want to get as much done at once as possible by the same person and you seem to know exactly what I want.

A: When it comes to vertical lengthening of the chin, that can not be done with an implant by more than few millilmeters. It would require a chin osteotomy or a custom chin implant to do that which, although can be done, adds to the cost of the procedure. I would just use a square chin implant of 9mms augmentation and position low on the chin bone so that is some degree of vertical lengthening. I believe that will more than suffice.

The trifecta of jaw angle implants and a chin augmentation are the best way to create a chiseled jawline. The key question in jaw angle implants is whether they should just be of the lateral augmentation type (just adds with to the jaw angle) or whether they should be of the vertical lengthening type with variable amounts of width addition. What most men who seek the chiseled jawline look need is the latter, some vertical lengthening and width addition to create a sharper and more defined jaw angle at the back of the jaw.

Your nose is slightly over rotated (tip up too high). The tip could be rotated downard to some degree using septal extension and tip only grafts during your rhinoplasty.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’ve seen a lot of photographs and I’m completely amused by the results of the surgeries you have performed. I’m 20 years old female and I’m very interested in chin reduction surgery as I feel that it makes my face too long and also when I smile or speak the muscle/soft tissue protrudes hence this makes it look even larger. I was wondering if I could send you some photographs of my chin so that you could consult me on what could be done to improve my appearance. I have attached photos of my chin and also the result that I would like ( using photoshop) Could you please tell me if it is even realistic to get such result from a chin reduction surgery and how it could be done.

A: Thank you for sending your imaged pictures of the desired result. Your chin concerns are that the center area if long and include both the vertical length of the bone and a soft tissue underhang. To achieve your result, which in my experience is very possible, requires a submentoplasty approach to your chin reduction. From an incision underneath the chin, the center bone could be burred down and smoothed into the sides and the soft tissue overhang could be removed and tucked up.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know rhinoplasty involves a lot of different surgical steps that affect the outcome of the surgery. But there must be different types of rhinoplasties based on whether you change just one part of the nose or different parts. I am trying to figure out what type of rhinoplasty is best for me. 

A: You are correct in your assumption that rhinoplasty involves a lot of different steps and no one rhinoplasty is exactly the same as the other. But there are some basic types of rhinoplasty which affect not only what part of the nose is being changed, but how long the operation lasts and how the length of recovery. I like to think of rhinoplasty as involving three different types which can be described as follows.

Type 1. This is a true tip rhinoplasty where the work lis imited to just the lower alar cartilages. No nasal bone or middle vault cartlaginous work is needed. Also there is no internal septal or turbinate work done. A tip rhinoplasty would actually be done most commonly in revision work for tip asymmetry and/or an adjustment but may occasionally be done as an isolated primary rhinoplasty. This is the quickest recovery of all the rhinoplasties. For the obvious reason I like to call this a TIP RHINOPLASTY.

Type 2.  =  This involves work done to the ip and middle vault cartilages of the nose but does not involve nasal osteotomies. (breaking the nasal bones) It may involve some rasping or smoothing of the nasal bones for minor hump deformities. Septal grafts may be harvested but not overall septal straightening or turbinate reduction most of the time. This collection of nasal procedures I call a RHINOPLASTY.

Type 3.  This is a complete ‘overall’ of the entire nose. It is complete nasal work from the tip to the nasal bones including osteotomies. Always needed when there is a signifincant hump reduction. Will almost always include a straightening septoplasty, graft harvests and inferior turbinate reductions. Because of treating both the internal nasal breathing and external appearance, it is called a SEPTORHINOPLASTY. This will involve the longest recovery of all the rhinoplasties which often causes temporary undereye bruising and nasal congestion and stuffiness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to possibly revise a scar from a surgery years ago that is 5-6 inches in length along the back right side of scalp up to above the right ear. I had cortisone injected into scar not long ago and it seems kind of depressed now.  The scar is covered by hair but I would like to shave my head as my hair is getting thinner and transplants are not really a goal at this time due to how thin the hair is becoming only making more problems. Any advice or consultations would be appreciated. 

A: The scalp scar you have appears as if it is from a hair transplant harvest procedure by its location and length. These scars can become visible when there is scar separation and the scalp hairs along the scar are not right up against each other. Wide scars are not going to be improved by steroid injections as that will not bring the edges any closer together. Rather it is donw what could be anticipated…creating a scar depression without narrowing the scar. The only way to improve your scalp scar is by excision of the non-hair bearing scar and bring the hair-bearing scalp skin edges closer together. Basically only a formal scalp scar revision will work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born with club feet. I had Achilles release surgery as a baby. I am now 25 and have been considering calf augmentation for a number of years.

A: Thank you for your iuquiry. It is quite common as you know that the associated calf on the clubfoot will have a smaller and more atrophic leg between the knee and ankle. While calf augmentation with an implant is a reasonable and standard approach for this problem, the unique issue with the ‘clubfoot calf’ is how tight the skin is around the calf area. This limits the size of the calf implant that can be placed and how much change (calf size increase) can actually be obtained. You can see that placing implants in a cosmetic calf concern where the skin and underlying soft tissues are soft and supple is quite different from that of a congenital calf deformity where the skin is more tight and less prone to stretch. It would be helpful to see pictures of your calfs and to know the actual circumferential measurement around the mid-portion of your calfs.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m now thinking I want to move forward with doing cheek implants and picked out the style of implant I want but need to know it the implant is falls into the category of small, medium or large. It’s by spectrum design and is called( malar profile ) the nominal dimensions are 5.4×3.2×0.5. But it doesn’t say if its a medium implant or large and this is something that is important for me to know. Pls help. Thank You. 

A: To help answer your question, here is the schematic on that particular cheek implant style.

Profile Malar Implants
	Catalog Number	NOMINAL DIMENSIONS
		A	B	C
	S140-414S	4.6 cm	2.3 cm	0.4 cm
	S140-424S	5.1 cm	2.7 cm	0.5 cm
	S140-434S	5.4 cm	3.2 cm	0.5 cm
	S140-444S	5.7 cm	3.5 cm	0.5 cm
	Sizer set 900-014		Designed to enhance the entire malar region, this implant features thin tapered edges and provides a smooth transition to the malar prominence.

You can think of the four options as Small, Medium, Large, and Extra Large.  Therefore what you inquiring about is S140-434S which would be considered a large implant. As you can see by this dimensional chart on cheek implants is that the thicknesses don’t differ that much but the surface area that they cover do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am finished having children and my body is a wreck. I have tried to get back close to my pre-pregancy body, but it is not happening. I want to have a Mommy Makeover procedure but my husband says I am just not working at it hard enough. When is a good age to have it done?

A: The effects that pregancy has on a woman’s body are largely irreversible by natural efforts for many women. Loose or separated abdominal muscles (rectus diastasis) can not be made to fuse back together by any amount of abdominal situps. Abdominal skin that has been stretched out and partially torn (stretch marks) can not have elasticity restored by situps, creams or weight loss. Breasts that have lost volume and sag can not be lifted up by chest exercises or alleged skin tightening creams. The onething a women can do is lose her pregnancy weight but all other changes require outside help

A so-called Mommy Makeover procedure, which combines breast augmentation with or without a lift and some form of a tummy tuck with or without liposuction, can be done at almost any age. But, by far, the majority of these procedures are done between the ages of 35 to 50. This is an age range where women are done having children and have proven to themselves that diet and exercise just can’t get the body improvement they desire. But age alone is not the only criteria. As long as one is finished breastfeeding, a Mommy Makeover can be done as soon as three to six months after one’s last pregancy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read most of the material on your website relative to skull reduction. I have a disproportionately large head and face compared to my body. If you burr my head, how many months it will take before I can see a result? Because I assume in this kind of operations you get lots of swelling and you don’t see a result right away. So, the head will look bigger before starting to look smaller. Most importantly, I am an active person and work out every single day (aerobic, elliptical, walks). For this kind of surgery, how many weeks should I take off from the work out? And what is the worst that can happen if I work out 10 days post op, for instance? Thanks

A: While the scalp will swell after any skull reshaping procedure (the bone doesn’t), it usually takes about three weeks before the initial results start to become apparent. It will take up to three months to see the final result. There is harm in returning to working out whenever you feel comfortable, even if it just 10 days after surgery. You can not hurt the surgical result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in silicone malar cheek implants and wanted a dramatic look to change the shape of my flat face. I for sure want to get a medium size implant and was wondering if a 3mm falls in that category or if a 4mm is considered a medium? Thank you.

A: The determination of size is but one consideration in the selection of a cheek implant. It would be equally important to select the style or shape of cheek implant that works best for your face and could create the look you are after. But back to size, a cheek implant’s size has numerous dimensions of which thickness is but just one of them. Generally as the thickness of the implant increases so does the height and width of it as well. (total surface area that it covers) Whether a 3mm thick cheek implant would be considered a ‘medium’ would depend on what cheek implant style you are talking about. For some silicone cheek implants such as the malar shell, 3mms in thickness would be considered an intermediate sized implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, This is for the nasal sill area and I am specifically interested in the cartilage injections to augment the sills which were removed in a bullhorn liplift. Will the injectable cartilage work for this indication? I would like to take care of that first since it can be done under local. What would be the price for cartilage injection in the sill area?

 The other procedure for premax augmentation don’t you also use mersilene mesh to augment that area or do you just use rib? I think rib might be better anyway except I would be afraid of warping.

A: If your goal is to try and stretch out skin in the nostril sill area, I don’t think this will work with any form of subcutaneous augmentation. It may provide a push but I can’t see how that will make up for lost skin along the nostril sill. In addition, placing injectable cartilage can not be done under local anesthesia. While the injections could be done under local, the cartilage must be harvested usually from the nasal septum which is not a local procedure. One simple way to easily prove whether an injectable approach will worko is to first have a temporary filler like Juevderm or Radiesse injected and see if that works. If it is successful then you can move forward with injecting cartilage.

Mersilene mesh can certainly be used for premaxillary augmentation just as rib can. I would have no concerns about rib warping as that is a function of how it is harvested so it is easy problem to avoid in an enbloc augmentation application.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am looking to improve my weak jawline. It is weak not only in the front but all the way to the back. I guess I was just borne with a small underdeveloped jaw. It makes me look very unmasculine and I would like to improve that as I think it would make my life better. I have read about implants that are used for the jawline but it is not clear to me whether I would need custom implants or not.

A: Facial augmentation can be done by a variety of implant approaches which fundamentally breakdown into off-the-shelf, semi-custom, or custom. Off-the shelf implants mean what is currently available in the catalog that the manufacturers have available and can ship with arrival in 1 to 2 days. A semi-custom implant approach means using what is available off-the shelf but modifying them during surgery to fit the patient’s anatomy and their aesthetic desires. Like off-the-shelf implants, they can be ordered and arrive in 1 to 2 days. A custom facial  implant approach is very unique because the implants are made off the patient’s model made from a 3-D CT scan either by hand or computer-generated. These take a certain amount of time to manufacture, which at the minimum is three weeks from when the patient gets their CT scan done locally.

To make the determination of which implant approach needs to be done for any particular patient I use computer imaging to get a feel for the magnitude of facial implant volume and changes that is needed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, do you do injectable cartilage? Can this be used to give support in the nostril sill area? My sills were partially removed from a bullhorn lip lift and I thought the cartilage injections might rebuild the area. Dr. Onor Emrol in Istanbul says the injectable cartilage can be used in this area but I can’t really travel that far and he doesn’t do phone consults. I have scarring at the base of the nose loss of nostril support from the liplift and the sills were partially removed due to where the incision was placed. Also can the injectable cartilage be used to do premaxillary augmentation. I want to move forward the nasolabial angle. The nasolabial angle is now caved in due to being scarred down from the liplift and I need to increase the angle push it away from my face.

A:  I have done numerous diced cartilage grafts, whether it is by injection or with a rolled graft fabrication in fascia or surgicel collagen material. The key questions are whether such cartilage grafts will work for your two indications and what volume is needed. From a premaxillary/paranasal augmentation standpoint, the issue with using cartilage is the volume of donor material needed. The septum will not have enough material to create enough push to make a visible difference in these areas. To get good volume, a lower rib donor source is needed where a good bloc can be removed and used. Whether one dices up the cartilage or injection below the skin and places it at the bony level in a carved form just like a synthetic paranasal-premaxillary implants is a matter for further discussion. From a nasal sill standpoint, the septum or ear will offer enough material to dice and injected beneath the scarred nasal sill area. While this will not replace lost skin that was removed from the lip lift, it will provide subcutaneous volume to push out on the area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got the gummy smile by V-shape process in Asia one year ago. It did not work for me. It looks like as before surgery. Can I get the new process for gummy smile in (Lip reposition method) again?

A: Even though you have had an unsuccessful V-Y upper lip mucosal advancement, you can proceed with further efforts at improving the gummy smile. I have found that while the V-Y mucosal procedure is a part of gummy smile surgery, it alone is not enough for a sustained correction. Elevator muscle release and a lowering vestibuloplasty must also be incorporated into the surgery for a sustained improvement. Your other option is to do Botox injections in the paranasal area. With just a few units of Botox, the muscle is relaxed and you will have less lip elevation for the duration of the drug’s effect. (4 months)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I wanted to send you a couple pictures to see what you might suggest. I have a very narrow jaw and a pointy, long chin. I would like to have it reduced in length, though I’m not sure what else would be necessary for my jaw to look proportionate. Thank you for your time.

A: Thank you for sending your pictures. There is no question that a vertical chin reduction osteotomy would be very helpful for your chin. The unique part about your vertical chin reduction, because of your very steep mandibular plane angle, is that the back part of the osteotomy behind the bony cut must be reduced (leveled) as well. Otherwise the chin will be vertically reduced but you will end up with a ‘box’ look to the chin as there would not be a smooth transition along the jawline between the end of the osteotomy and the rest of the jawline as it heads back to the angles. I have done some predictive imaging to show what the potential changes could look like. Based on these predictions I see no need to alter your jaw angle area even though they are high. They could be lowered with implants but I am afraid this will make your entire lower face ‘too heavy’ even though it may be better from a jawline perspective. For now I have not imaged such changes but can if you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to ask a rhinoplasty question. Since my primary motivation for getting any work done is to improve my smile. In a rhinoplasty where you reduce the nasal spine as we discussed, would there be a possible side effect of lengthening the distance between the nose and mouth? In my imagination, by eliminating some of the protruding cartilage in that area, the tissue and skin that currently exists there would be pulled back into that void, thus pulling up the lip slightly. However, I’m not sure if that’s even how the anatomy works. Is the tissue anchored to that area and would it need to re-anchor itself or would it just drape down further, thus lengthening the lip?

A: Your question is a good one. Theoretically by removing the nasal spine, your assumption is most likely correct that the tissue should be pulled back up into the removed area potentially lifting the lip somewhat. In reality, probably very little lip lift actually occurs. There have been a few reported instances where lips have lengthened as a result but that is not something that I have ever seen. One would not, however, try to anchor the tissues to the removed nasal spine area as that may potentially cause a tethering/tightness when one smiles. It is much better to let the area heal naturally rather than try to treat a potential problem which may never occur…and in the process create a whole new one.

The way I view your rhinoplasty, and is the reverse of the the concern of upper lip lengthening, is that the rhinoplasty is potentially setting up a subnasal lip. So whatever happens to the lip length (particularly if there is some lengthening) does not matter because you likely moving on to a lip lift anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you do tummy tucks scheduled and coordinated with a hysterectomy. What the cost would be and how much of a cost savings would it be. I am not only looking into having them done at the same time for cost savings (insurance will pay for the hysterectomy but NOT the tummy tuck) but for combining recovery time as well. Can a lower body lift (instead of a tummy tuck) be combined with the hysterectomy? A little info on me.  I am a 40 year old female, about 20 months post op from bariatric surgery. I have lost about 160 to 165 lbs and now weigh about 167 and weight has pretty much stabilized the last 4 to 6 months. I am 5’3″ and happy at the weight I am at now, but the hanging excess skin is really bothering me, in the way, clothes don’t fit right, it gets sweaty under the fold, and it is very uncomfortable. Thank you for you any information you can provide me and for your time.

A: Congratulations on your successful weight loss! Either a tummy tuck or a circumferential body lift can be performed at the same time as a hysterectomy. This is an historically common combined abdominal procedure. Besides the obvious benefit of one single combined recovery, the only key question is how do the economics work out. Since you will be paying out of your pocket for either a tummy tuck or a body lift, the question is what is the OR and anesthesia cost if done in a hospital with the hysterectomy compared to it being done separately in an independent surgery center? (the plastic surgeon’s fee would be the same at either location) Many patients would assume they are similar but that is often mistaken. Either location of the surgery should be priced out so you can see the difference between your fees. If the difference is small, then one should have the body contouring procedure done at the same time as the hysterectomy. But if the difference in significant (thousands of dollars) that may give one pause as to whether it should be done separately. You may ponder as to why there would ever be a difference between the two locations (hospital vs surgery center), the answer is simple….overhead and efficiency.

I will have my assistant calculate those specific costs between the two locations for just one of the procedures (tummy tuck) so we can see how different or similar those costs would be.

Dr. Barry Eppley

Indianapolis, Indiana